2.0 Analysis 2.1 Introduction The accident aircraft was adequately equipped and maintained for VFR flight, and there were no pre-impact mechanical failures. There is nothing to suggest that the aircraft load was a contributing factor, and there was nothing to indicate loss of control before the aircraft struck the trees in straight-and-level flight. 2.2 Seats/Seat-belts (Survivability) No conclusion could be made as to whether there might have been additional survivors had the seats been more securely attached to the airframe. However, there is no doubt that additional injuries occurred as a result of the seats breaking free. Injuries to the pilot and the front-seat passenger would have been lessened had the pilot been wearing the available shoulder harness. 2.3 Regulations for VFR/SVFR The 1990 TSB safety study found that CFIT accidents involving VFR aircraft were linked to flight in marginal weather conditions, and that regulations provided inadequate safety margins. At that time, the Board was concerned that the amendment to Air Navigation Order (ANO) Series V, No. 1 (June 1990) that eliminated the sliding scale authorizing SVFR would lead to greater use of SVFR in weather conditions worse than those which permitted the studied accident flights to occur. Accordingly, the Board recommended that: The Department of Transport reconsider the decision to reduce SVFR weather minima to visibilities of one mile. Transport Canada responded that this recommendation would be addressed by the VFR working group. To date, the SVFR weather minima remain unchanged. It was apparent during the investigation of this accident that, in fact, the use of SVFR in such weather conditions had become an accepted norm in the Campbell River control zone. It is important to note that, prior to June 1990, an SVFR clearance would not have been approved for the accident flight because of the reported weather conditions and the pilot would not have been able to continue with his plan to land at the Campbell River airport. 2.4 Decision to Fly to the Airport As the aircraft approached Campbell River, the pilot had two options to continue visual flight: to attempt to land at the airport, or to land at Tyee Spit. When he overflew Tyee Spit, the pilot was aware of the official weather reports from the airport; however, he was also aware of the fact that another aircraft on approach to runway 11 had reported a better ceiling than the official report. The pilot's decision to fly to the airport is consistent with the accepted industry and local practice of taking a look at the conditions, and with the pilot's own history of operating in such conditions. Once he obtained SVFR, he could attempt the airport landing without violating any weather limits. Given the flight route and altitude flown, it appears that he either ignored, or was not aware of, the minimum altitude order which would have required him to maintain a minimum of 500 feet agl over populous areas. After the pilot turned back from his initial attempt to fly directly to the airport, the track of the aircraft, as recorded by radar, is consistent with an attempt to proceed outbound parallel to the ILS for runway 11, and then turn onto a heading to intercept the localizer inbound in the area of the Campbell River NDB. This hypothesis is supported by the settings on the navigation equipment. Although the pilot may have considered the option of conducting an instrument approach at that point, there is no indication that he had attempted to do so. The pilot may have been influenced by either his assessment of the weather conditions as being still suitable for SVFR flight, or a possible reluctance to violate the company's operating certificate which restricted operation of the aircraft to VFR. The aircraft was in straight-and-level flight at impact. This suggests either that flight visibility was such that the mountain was totally obscured, or that the aircraft had entered cloud; this also suggests that the pilot had lost situational awareness and did not see the rising terrain until it was too late to avoid a collision. 2.5 Summary Had the flight been completed successfully, it would have been viewed as just another normal flight. The pilot's decision to try to get to the airport in marginal weather conditions is consistent with both his past practice and the industry-accepted norms for this type of operation, and led to the progressive erosion of his situational awareness. It is apparent that he was attempting to use visual flight, supplemented by IFR navigational methods. In such marginal weather conditions, this combination does not provide the level of protection normally associated with either flight regime, in that pilots are restricted in their ability to navigate visually, and are not protected by the minimum obstruction clearance altitude restrictions imposed by IFR navigation. Accident statistics consistently show that VFR flight in marginal weather imposes a significant risk. More stringent regulations, as previously recommended by the Board, might have led the pilot to alter his plan to fly to the airport. 3.0 Conclusions 3.1 Findings The pilot was certified and qualified in accordance with existing regulations, and there was no indication that incapacitation or physiological or psychological factors affected his performance. There were no indications of any pre-impact failures or aircraft malfunctions that could have contributed to the occurrence. For the entire flight, the aircraft was operating outside its certified weight and balance envelope. This was not found to be contributory to the accident. Review of the aircraft journey log entries indicates there were other flights where the aircraft weight and balance were also in excess of the approved limits for the aircraft. At the time of the accident, the aircraft's engine was 92.8 hours over the 1,250 hours of operating time allowed between hot section inspections. This was not found to be contributory to the accident. Although the weight and balance and engine discrepancies were not found to be contributory, they indicate inadequate management supervision in these areas. The degree of company supervision of the operations and maintenance functions at Western Straits Air was found to be typical of other such companies offering similar services. DHC-3 Otter passenger seats do not meet current design standards, nor is this required by regulation. The pilot was not wearing the available shoulder harness and was thrown into the front-seat passenger on impact. This contributed to the injuries suffered by both the pilot and the passenger. Failure of the passenger seats to remain attached to the airframe contributed to the extent of the injuries suffered by the occupants. The continued flight into marginal weather conditions resulted in the progressive loss of the pilot's situational awareness and the collision with the terrain. The pilot's decision to continue the flight into marginal weather conditions was probably influenced by the prevailing industry attitudes and practices regarding VFR and SVFR operations. In the marginal weather of this occurrence, the pilot's use of visual flight procedures supplemented by IFR navigational methods did not provide the level of safety normally associated with either regime. The regulations governing VFR and SVFR commercial operations at the time of this accident were the same as the regulations assessed in the 1990 TSB safety study as providing inadequate safety margins. 3.2 Causes The pilot progressively lost situational awareness while attempting to navigate in conditions of low visibility or in cloud and was unaware of the rapidly rising terrain in his flight path. Contributing to this accident were the existing visual flight regulations and the prevailing industry attitudes and practices which did not provide adequate safety margins. Contributing to the severity of the injuries was the detachment of the passenger seats at impact. 4.0 Safety Action 4.1 Action Taken 4.1.1 Seating and Restraint System Subsequent to this accident, the TSB issued a safety advisory to Transport Canada (TC) identifying a concern that seating and restraint systems of some aging aircraft do not provide adequate protection to passengers in the event of a crash or forced landing. Aircraft systems are being modernized to extend their useful lives for commercial passenger-carrying operations, but these upgrades seldom include the improved passenger safety provisions consistent with contemporary standards. Thus, the TSB suggested that TC take a more systems-oriented approach in approving such life-extension programs. 4.1.2 Engine Condition Trend Monitoring During the investigation, it was established that the ECTM program, which formed part of the approved maintenance program for the turbine engine installation on C-FEBX, had not been used as per Transport Canada's approval. It was also determined that some of the TC airworthiness inspectors responsible for the Western Straits Air maintenance system were not trained in trend monitoring programs. The TSB subsequently advised TC of this issue and suggested that TC consider adding ECTM to the airworthiness inspectors' training curriculum. 4.2 Action Required Air Regulations and Air Navigation Orders established under the Aeronautics Act, such as those governing VFR and SVFR flights, prescribe operating limits. Such limits are designed to provide operational flexibility, while ensuring minimum acceptable safety margins. Such regulations are influential elements in determining industry operational practices and in establishing the level of safety of the transportation system. The Campbell River accident raises questions regarding the feasibility of VFR and SVFR flights in marginal weather conditions, considering pilots' limited capability to recognize deteriorating visibility, the adequacy of the margin of safety afforded by VFR and SVFR regulations, and the level of operators' awareness of the risks associated with commercial operations in marginal weather conditions. 4.2.1 Visual Flight - Margin of Safety